Wednesday, February 28, 2007

MRSA is in the news. What is it? MRSA is a type of infectious skin disease spreading into BJJ, Judo, MMA and grappling schools as well as infiltrating it's way into wrestling programs and other contact sports programs. It is contagious, it is ferocious, and yes, it can kill you if left untreated.

MRSA is an acronym for Methicillin-resistant Staphylococcus aureus. MRSA is also known as oxacillin-resistant Staphylococcus aureus (ORSA) and multiple-resistant Staphylococcus aureus. Staphylococcus aureus (S. aureus) (shown above) is a bacterium that is the leading cause of staph infections. The types of infections this bacterium can cause range from pimples, boils and abscesses to more serious and life threatening infections such as pneumonia, meningitis, endocarditis, toxic shock syndrome and septicemia. The S. aureus bacteria can live harmlessly on the human body on the scalp, groin and armpits, and can also colonize in the nostrils, throat, urinary tract and open wounds. Penicillin was originally used to treat S. aureus infections, however, today, approximately 80% of all S. aureus bacterium are penicillin resistant. In 1959, Methicillin was employed as an antibiotic to treat infections caused by penicillin resistant S. aureus. However, in 1961 the first case of Methicillin-resistant S. aureus was reported in a hospital in England. Yet, MRSA was a relatively uncommon finding in hospitals until the 1990's when it exploded in prevalence and is now considered endemic (endemic: meaning that in order for the infection to sustain itself, one infected person must pass the infection on to one other person). MRSA infections were typically confined to hospital settings (HA-MRSA, hospital associated-MRSA), however it has since broken free from the post-surgical wards and become prevalent in the community (CA-MRSA, community associated-MRSA). S. aureus strains that can still be treated with methicillin have since been termed as Methicillin Sensitive Staphylococcus aureus, or MSSA. It is evident, that the over use of antibiotics for less than severe infections has lead to the evolution of resistant strains of bacterium such as MRSA. MRSA (shown in photo below) can cause skin infections as mild as skin boils to as severe as necrotizing faciitis (flesh eating disease). If left untreated, the infections can lead to septicemia, pneumonia, meningitis, endocarditis, and toxic shock syndrome - all of which can be lethal to humans.

Aside from the wrestling and grappling mats, MRSA transmission has been reported to occur in the palors of UNLICENSED tattoo artists (no cases have been reported from reputable parlors and artists) (reference: Centers for Disease Control, MMWR 55: pg. 677-679, June 22, 2006.), as well as through HETEROSEXUAL sexual intercourse (Cook H et al., 2007. Clin Infect Dis 44: pg 410-413.)

Typically, vancomycin and teicoplanin have been the most commonly employed antibiotics used to combat MRSA infections, and are often administered intravenously. However, the S. aureus bacterium are a rapidly evolving microorganism and in 1996 in Japan it was found that some strains of MRSA have developed resistance to these countermeasures as well. These new MRSA strains were called Vancomycin Intermediate-resistant Staphylococcus aureus (VISA). By 2002, the strains with with intermediate resistance to vancomycin became more robust and developed into bonafide VRSA strains (Vancomycin Resistant Staphylococcus aureus). As of 2005, 3 cases of VRSA have been reported in the United States.

Preventative Measures: anti-Microbial Agents

The use of anti-microbial agents can be employed as a preventative measure to stave off infection from bacteria and fungi. Their use is wide spread in a variety of household products such as dish soaps, toothpastes, mouthwashes, disinfectant wipes, skin care products, children's toys, clothes and textiles and plasticware. One of the most common anti-microbial agents (also called biocides) in use is Triclosan (also known as Irgasan).

Why Triclosan? In 1995 there was a MRSA endemic in a neo-natal intensive care unit and the staff at the hospital began washing their hands with soap containing Triclosan. This preventative measure as well as treating the infected infants with anitbiotics stemmed the spread of the infection. Since then Triclosan has been considered the #1 antimicrobial agent to prevent the infection of MRSA. Adult patients with dermal MRSA infections are often given baths containing 2% Triclosan to help kill the bacteria. The Triclosan molecules bind to and inhibit proteins that are critical for fatty acid synthesis within the bacteria cell, and hence are important for not only cellular metabolism, but also the construction and maintenance of the cellular membrane.

Triclosan (5-chloro-2-(2,4-dichlorophenoxy)-phenol) is a powerful chemical antibaterial and antifungal agent. Triclosan has been used more frequently in recent years for the anti-microbial treatment of fabrics (both natural and synthetic) that make up both everyday clothes as well as sport specific and activity wear. The Ciba Specialty Chemical Corporation sells it's Ciba Tinosan AM 100 (TM), which contains Triclosan, to textile companies for impregnation into fabrics.

Grappling specific products have been made that contain Ciba Tinosan (TM). There are rash guards, grappling shorts and skin care products that are sold by OTM.com, and Kennedy Industries is a leader in skin and mat care/cleansing regarding antimicrobial agents (primarily "KenShield (TM) Skin Creme"). While these are great preventative measures against acquiring MRSA bacterium and becoming infected, proper personal hygiene following training sessions is always a must. Using an antibacterial soap that contains Triclosan (if a product contains Triclosan it must state so on the label as mandated by the FDA and EPA) is a measure that one can employ. However, in those individuals with healthy immune systems, regular soap or shower gel should suffice. Unfortunately, a popular soap/shower gel touted amongst the wrestling and grappling communities, Defense Soap (TM) has yet to show effectiveness against S. aureus (MSSA) or the more dangerous MRSA upon review of their clinical report.

The Downside to Triclosan?

It is hypothesized, and even highly likely, that both MRSA, MSSA could develop resistance to Triclosan. Reports have shown that strains of E. coli and Salmonella enterica have possibly developed Triclosan resistance, and some other bacterium have a natural resistance to the biocide. Resistance to Triclosan has been developed in the laboratory when MRSA bacterium have been subjected to less than lethal doses of the agent. When used at "full dose", Triclosan (and it's treated products) is lethal to many microorganisms (MRSA, MSSA, certain fungi, etc.). However, at lesser doses it has been shown that MRSA strains can acquire resistance in a laboratory setting. It is therefore possible that Triclosan treated products could lose adequate concentrations of the biocide (from wearing and washing) over time, and contain less than adequate doses of the Triclosan protectant, thereby allowing for an environment where these microorganisms can develop resistance. However, several major scientific studies have shown that MRSA strains in the wild (outside the lab) can not, or have not (yet), developed resistance to Triclosan.

Tree Huggers Don't Like TriclosanIn one scientific report it was suggested that Triclosan can bind to chlorine compounds in tap water to form chloroform, which is classified as a possible carcinogen by the EPA. Upon interaction with chlorine and other compounds in water, Triclosan can produce intermediate compounds that, when exposed to ultra violet radiation (sun light), convert to dioxins that can contaminate the water and soil. It is uncertain at this time how readily Triclosan converts to dioxins in the wild or how dangerous the dioxins might be, but studies are still on-going in this area.

To Wear, or not to Wear?

In my opinion, I would only wear Triclosan (Ciba Tinosan (TM)) clothing and use Triclosan skin products if I were a person with a compromised immune system, in a gym with a high class attendance, in a gym with previous outbreaks of Staph infection, or I regularly attended large scale tournaments. But this is only my personal opinion. I would, regardless of healthiness, take care of every cut, scrape or laceration with antibacterial agents (Neosporin, etc.) and always take my full course of perscribed antibiotics when fighting a serious bacterial infection. All too often we hear or read of otherwise healthy individuals contracting a MRSA infection and winding up in the hospital. It could happen to you. Proper personal hygiene such as showering within an hour of training sessions, using adequately hot water, lathering up and allowing the soap to sit on the skin for 30 seconds or more before rinsing, washing gis and other training apparel after every use (not every other use or longer!) and regularly washing bedding and clothes is critical to preventing infection from MRSA and other microorganisms including ringworm. Also, pay attention to your body and monitor odd looking red spots, pimple like bumps and bumps that look like spider bites on your skin. If the "pimple" begins to develop red streaks or rings emanating from it, you might have a staph infection - go see a doctor.

Thanks, Caleb! I plan on using the medical literature databases available to me (via work) to write about the more medical and scientific topics. There's also a surprising amount of reasearch that's been done on Judo (falling, injuries, techniques, etc.).

Great post. Quick question: I train twice per week. If I use a Triclosan containing product (such as Dial Antibacterial Shower Gel) everyday, does it build up an anti-bacterial barrier on your skin (such as Physo-Hex, which is by prescription only, does)? Thanks!

To the best of my knowledge, Triclosan soap products do not have the same accumlative properties as Phisohex (http://www.rxlist.com/cgi/generic/hexchlorph.htm). However, it is advertised that fabrics impregnated with Triclosan retain the chemical properties for a long time. How long is a long time? I don't know.

Additionally, the accumalitve properties of Phisohex also bring with it a whole new list of side effects and unique possible dangers. Chemicals in the cleanser can be absorbed through the skin and have been found in the blood samples of patients.

As a physician, I see MRSA infections frequently in the hospital. I had just a few random comments.

As for the antibacterial ointments and Triclosan, if it hasn't become resistant by now, it will very shortly. Frequent exposure to any antibacterial especially weaker doses (like in ointments or clothing) is a recipe for resistance.

The best defense is what you said about showering shortly after practice and washing gis often. In the hospital, handwashing is shown to be the best prevention. This doesn't always happen in the hospital or nursing homes or even family caregivers.

A study about 10 years ago had shown that about 30% of hospital workers (including docs) actually have MRSA colonized in their nose. This isn't usually a problem for the immune-competent unless trauma is induced.

For a lot of frequent flyer patients in the hospital, Vancomycin is first line treatment due to the frequency of MRSA in that population. I've seen a couple Vanco-resistant MRSA in the hospital (we never actually call it VISA, that's more of a journal term), they get treated with Teicoplanin or Daptomycin or Synercid, all IV.

You can actually get "regular" Staph aureus infections (non-resistant kind) that look the same as the impetigo picture in your post. These are more common, have always been around, and are the usual "staph infection" grapplers talk about. The only difference being these usually respond to oral antibiotics if caught in time. Same rules as you stated above apply to preventing infection - hygeine. (MRSA generally doesn't have oral antibiotic options - you need an IV).

The other skin infection grapplers can get is from a herpes virus named herpes gladiatorum (great name). It isn't usually the "golden crusty" rash of Staph/impetigo but more of a shingles "raised bubbly bumps" rash.

MRSA is also becoming more common in people who frequent strip clubs (again due to the close physical contact). So if you get it even while skipping practice, you might have some 'splainin' to do, Lucy (an old I Love Lucy joke there).

Thanks for the comment, Scott. It's great to have the opinions of experts on here.

It's interesting, and I don't know how true it is... but a couple of weeks ago I was watching CNN and the ticker at the bottom of the screen read, "In the last year, more people world wide have died from MRSA related infections than HIV/AIDS." It didn't cite a source, but I plan on surfing the CDC website to see what I find.

The MRSA quote doesn't surprise me. So many of older people with chronic medical problems get MRSA just from being in and out of the hospital or dialysis or nursing homes several times a year. If they don't die OF MRSA, they definitely die WITH it.

By the way, you were an awesome teacher at Focus and U-M BJJ. Hopefully you can keep up with this blog too. Great articles and unique insight here.

Shoot me an email when you get a chance. When some medical stuff comes up on here, I'd like to have an expert explain or elaborate on the matters that I fall short on.

My teaching skills are fast approaching the extreme test. I am searching for, and have found takers for a BJJ school in my new location. I plan on opening a SRJJA BJJ school in the Iowa City/Coralville, Iowa area. Most of these places are Tae Kwon Do dojos with crappy mats that want a BJJ ciriculum. So, I'm looking and negotiating with some people. I'm also consulting with all of the SRJJA guys who have already done what I am trying to do. I'm attempting to learn from their mistakes.

I'm glad you liked my teaching. I worry about my teaching. I try to compensate for the lack of information that I got as a white/blue belt. But, I tend to overexplain and go way too far in depth on one particular move. Which means it takes me 2 hours to teach 3 moves/techs/positions. Some people like it, some don't. I love more information than less, as long as it's not a repeat. I need to get my teaching method down to 3 moves in 30 - 40 min. People need time to roll in a 1.5 hr class.

My email is either, jasonclk@gmail.com (here/social) or jason-clarke@uiowa.edu (professional/social). Hit me up at either one. I love what you have to say this stuff and all things medical/BJJ.

My nephew contracted MRSA while in a wrestling tournament. I really hope that a more effective treatment is found soon. Every year there is an outbreak somewhere and unfortunately it affects high schools.